Med3C Abarra - Pneumonia Pulmo

Course: Pulmonology Week: 15

Lect urer: Dra. Abarra Topic: Pneumonia
Source: Lecture

Table  of  Contents   British  Thoracic  Society  ..................................................................................  9  

Drug  Resistant  S.  pneumoniae  Therapeutic  Working  Group  .......................  9  
Introduction  .................................................................................................  2   American  Thoracic  Society  .............................................................................  9  
Pathophysiology  ..........................................................................................  2   Infectious  Dses  Society  of  America  ...............................................................  9  
Normal  oropharynx  .................................................................................  2   Canadian  Infectious  Dse  Society  &  Canadian  Thoracic  Society  ....................  9  
Inhalation  pneumonia  ..............................................................................  2   Guidelines  for  Empirical  Oral  Outpatient  Treatment  of  Immunocompetent  
Aspiration  of  oropharyngeal  secretions  .................................................  2   Adults  with  CAP:  MILD  TO  MODERATE  or  SEVERE  DSE  ....................................  9  
Aerosolization  ..........................................................................................  2   British  Thoracic  Society  ..................................................................................  9  
Epidemiology  ...............................................................................................  2   Drug  Resistant  S.  pneumoniae  Therapeutic  Working  Group  .......................  9  
American  Thoracic  Society  .............................................................................  9  
Community-­‐Acquired  Pneumonia  (CAP)  .................................................  2   Infectious  Dses  Society  of  America  ...............................................................  9  
Common  Causes  of  Community-­‐Acquired  Pneumonia  in  Patients  Who  ..........  3  
Canadian  Infectious  Dse  Society  and  Canadian  Thoracic  Society  ................  9  
CAP  Age-­‐Related  Factors  .....................................................................................  2  
Empiric  Treatment-­‐  Philippine    Consensus  Guidelines  .....................................  10  
CAP  Personal  Habits  ............................................................................................  3  
Low  Risk  CAP  .................................................................................................  10  
Alcohol  consumption  ......................................................................................  3  
Moderate  Risk  CAP  ........................................................................................  10  
Smoking  ...........................................................................................................  3  
High  Risk  CAP  .................................................................................................  10  
CAP  Co-­‐morbidities  ..............................................................................................  3  
COPD  ...............................................................................................................  3  
Adjustments  in  Antimicrobial  Therapy  ..................................................  10  
Bronchitis  and  pneumonia  .............................................................................  3   Common  Causes  of  Pyogenic  Pneumonia  ......................................  10  
Other  comorbidities   .......................................................................................  3   Streptococcus  pneumoniae  (Pneumococcal  Pneumonia)  .......................  10  
CAP  Geographic  and  Occupational  Considerations  ...........................................  3   Epidemiology  ..........................................................................................  10  
Hospital-­‐Acquired  (Nosocomial)  Pneumonia  (HAP_  .............................   4   Clinical  Manifestations  ...........................................................................  10  
Early-­‐onset  HAP  (<5  days  of  hospitalization)  .....................................................  4   Radiographic  Diagnosis  .........................................................................  10  
Late-­‐onset  HAP  (>5  days  of  hospitalization)  ......................................................  4   Microbiologic  Diagnosis  .........................................................................  10  
Factors  that  increase  the  risk  of  HAP  .................................................................  4  
Clinical  Course  ........................................................................................  10  
Health  Care–Associated  Pneumonia  ......................................................   4  
Other  Streptococci  .....................................................................................  11  
Ventilator  Associated  Pneumonia  (VAP)  ...............................................   4  
High  Risk  Criteria  .................................................................................................  4   S.  pyogenes  (group  A  β-­‐hemolytic  streptococcus)  ................................  11  
Nursing  Home-­‐Acquired  Pneumonia  .....................................................   4   Group  B  streptococci  (S.  agalactiae)  ......................................................  11  
Typical  vs  Atypical  Pneumonia  Syndrome  .............................................   4   The  Streptococcus  milleri  group  C  streptococci  ....................................  11  
Atypical  pneumonia  ............................................................................................  4   Clinical  Manifestations  ............................................................................  11  
Typical  Pneumonia  ..............................................................................................  4   Microbiologic  Diagnosis  ..........................................................................  11  
Patient  Evaluation  .......................................................................................  5   Complications  ..........................................................................................  11  
Clinical  Evaluation  ....................................................................................  5   Chlamydophila  pneumoniae  .......................................................................  11  
Clues  to  etiologic  dx  outside  RT  ..............................................................  5   Haemophilus  influenzae  ............................................................................  11  
Laboratory  Evaluation  .............................................................................  5   Mycoplasma  pneumoniae  ..........................................................................  11  
Procalcitonin  ........................................................................................................  5   Staphylococcus  aureus      ............................................................................  12  
Radiographic  Evaluation  ..........................................................................  5   Epidemiology  ..........................................................................................  12  
Chest  X  ray  (PA-­‐Lateral    views)  ...........................................................................  5   MRSA-­‐CAP  ..........................................................................................................  12  
Microbiologic  Evaluation  .........................................................................  5   Risk  Factors  ............................................................................................  12  
T32-­‐5  Recommended  Microbiologic  Evaluation  in  Patients  with  CAP  ..............  6   Postinfluenza  bacterial  pneumonia  ..................................................................  12  
T32-­‐16  Recommended  Microbiologic  Evaluation  in  Pts  with  Non-­‐Resolving   Clinical  Manifestations  ...........................................................................  12  
Pneumonia  ...........................................................................................................  6   Pseudomonas  aeruginosa  and  Related  Organisms      ................................  12  
Examination  of  the  Sputum  ................................................................................  6  
Epidemiology  ..........................................................................................  12  
Clinical  Indications  for  More  Extensive  Testing  in  Community-­‐Acquired  
CAP  ......................................................................................................................  12  
Pneumonia  ...........................................................................................................  6  
HAP  and  VAP  ......................................................................................................  12  
Blood  and  Pleural  Fluid  Cultures  ............................................................  6  
Clinical  Manifestations  ...........................................................................  12  
Antigen  Detection  ...................................................................................  6  
Microbiologic  Diagnosis  .........................................................................  12  
Serologic  techniques  ..............................................................................  6  
Clinical  Course  ........................................................................................  12  
Invasive  Diagnostic  Techniques  .............................................................  6  
Acinetobacter  baumanii      ..........................................................................  13  
Bronchoscopic  Samples  ......................................................................................  6  
Transthoracic  Lung  Aspiration  ............................................................................  6  
Epidemiology  ..........................................................................................  13  
CAP  ......................................................................................................................  13  
Therapeutic  Approach  to  Pneumonia  ........................................................  7  
HAP  .....................................................................................................................  13  
The  PSI  (Pneumonia  Severity  Index)  .......................................................  7  
Clinical  Manifestations  ...........................................................................  13  
T32-­‐9  Scoring  System  for  Determining  Risk  of  Complications  in  Pts  w/CAP  ....  7  
Microbiologic  Diagnosis  .........................................................................  13  
CURB  65  ....................................................................................................  7  
Clinical  Course  ........................................................................................  13  
American  Thoracic  Society  Criteria  for  Admission  of  Pts  w/CAP  to  an  
Lung  Abscess  ..............................................................................................  13  
ICU  ............................................................................................................  7  
Minor  Criteria  .......................................................................................................  7   Imaging  Studies  .........................................................................................  13  
Major  Criteria  .......................................................................................................  7   Chest  Radiograph  ...................................................................................  13  
Phil  Clinical  Practice  Guidelines  ..............................................................  8   Pulmonary  CT  Scan  ................................................................................  13  
Clinical  features  of  patients  with  CAP    according  to  risk  categories  ................  8   Other  .......................................................................................................  13  
Algorithm  for  the  management–oriented  risk  stratification  of  CAP  in   Prevention  ..................................................................................................  13  
immunocompetent  Adults  ..................................................................................  8   Vaccinations  ...........................................................................................  13  
Selection  of  Antimicrobial  Agents  .........................................................  8   Recommendations  for  Administration  of  Influenza  Vaccine  ...........................  13  
Guidelines  for  Empirical  Oral  Outpatient  Treatment  of  Immunocompetent   Key  Points  ..................................................................................................  14  
Adults  with  Community-­‐Acquired  Pneumonia      .................................................  9  
Lecture 1 mra
Med3C Abarra - Pneumonia Pulmo

INTRODUCTION Inhalation pneumonia

• Estimated 4 million cases of CAP/yr in the United
States
o ~10 million physician visits
o 1 million hospitalizations
o 45,000 deaths
• Mortality of CAP
o in hospitalized patients - 14%
o require ICU care - 20- 50%
•
rd
In the Phils - 3 leading cause of morbidity & mortality
based on Phil Health Statistics of DOH
PATHOPHYSIOLOGY
Normal oropharynx
• Predominated by a mixed flora of low virulence.
• Ability of virulent microorgs to colonize oropharynx is
determined by interaction of specific microbial
adhesins with cellular receptors
o Streptococcus pneumoniae, Staphylococcus
aureus, Pseudomonas aeruginosa, and Klebsiella
pneumoniae
• Glycoproteins (fibronectin) in oral mucus
o promote adherence of viridans streptococci
and
o prevent colonization of oropharynx by gram-
negative bacilli
o ↑Colonization in persons w/lower levels of
salivary fibronectin, consequent to alcoholism,
diabetes, malnutrition, and other severe
comorbidities
• Gram-negative bacillus colonization also occurs when new
receptors appear in surface of epithelial cells
o Occurs following influenza infection or in
COPD
• Complex interactions between virulence and quantity of
inhaled or aspirated microorganisms and the integrity of
mechanical barriers as well as of innate and adaptive
immunity determine whether pneumonia develops.
• Disruption of factors that regulate bacterial adherence to
mucosal surfaces facilitates oropharyngeal colonization by
more pathogenic microorganisms.
Most often due to microorganisms that
1. Survive long enough while suspended in the air to be
transported far from the initial source
2. Have a size <5um and carry a high inoculum
3. Evade local host defenses
Aspiration of oropharyngeal secretions
• Main mxn of contamination of lower airways by
large bacteria.
• Awake - normal glottal reflexes prevent aspiration
• Asleep - 50% of normal persons aspirate small volumes of
pharyngeal secretions
o Healthy adults - 10 to 100 million
bacteria/mL of secretions
§ W/periodontal dse - ↑100- to 1000-fold
• Aspiration of 0.001mL = inoculum of >100,000
microorganisms
• Disease due to S. pneumoniae, Haemophilus influenzae,
gram-negative bacilli, and related organisms is due to
aspiration.
• Aside from inhalational pneumonia due to Legionella or
contaminated medical aerosols
o aspiration is the cause of hospital-
acquired pneumonia (HAP), especially in
intubated patients.
• Biofilms are a well-recognized reservoir of bacteria that
facilitate the development of HAP.
Aerosolization
• Route of infection by intracellular bacteria such as
• Mycoplasma pneumoniae, Chlamydophila spp., and
Coxiella burnetii

EPIDEMIOLOGY
Community-Acquired Pneumonia (CAP) Children younger • S. pneumoniae
• True incidence: uncertain than 2 years • Respiratory syncytial virus (RSV)
• Only 20-50% of patients require hospitalization. Older children and • M. pneumoniae
• ~2 to 15 cases/1000 persons/yr (higher in elderly) young adult
• Severity of disease is largely determined by Elderly - particularly • Pneumococcal pneumonia
o Subject's age at risk for o GBS
o Presence and type of any coexisting illness o Moraxella catarrhalis
o H. influenzae
CAP Age-Related Factors o L. pneumophila
o Gram-negative bacilli
• Children - one of major causes of morbidity
o C. pneumoniae
• Adults - ↑age is associated with
o Polymicrobial infections
o a change in distrib of microbial causes and
Older than 80 years • Higher incidence of aspiration
o ↑frequency and ↑severity of pneumonia
pneumonia
• Although absolute rate of infection by M. pneumonia
• Lower incidence of Legionella spp.
o does not decrease with age
o h/e accounts for a smaller proportion of
pneumonia in elderly than in younger populations.

Lecture 2 mra
Med3C Abarra - Pneumonia Pulmo

CAP Personal Habits Bronchitis  and  pneumonia    

Alcohol  consumption     • Major causes of morbidity & mortality in pt w/cystic
• Important risk factor for CAP fibrosis
• Immunosuppressive effects • First decade of life - S. aureus and nontypeable H.
• Potential to lower consciousness level risk of aspiration influenza ( P. aeruginosa - infants)
pneumonia • By 18 years of age
• Independent risk factor for an increased rate and o 80% with cystic fibrosis harbor P. aeruginosa
severity of pneumonia, especially that due to S. o 3.5% harbor Burkholderia cepacia,
pneumoniae Stenotrophomonas maltophilia, Achromobacter
• Persists several months after cessation of alcohol xylosoxidans, and nontuberculous mycobacteria
consumption Other  comorbidities    
  • Congestive heart failure, chronic kidney or liver disease
Smoking     • Cancer, diabetes, dementia, cerebrovascular diseases, and
• Associated with CAP due to S. pneumoniae , L. immunodeficiency states
pneumophila , and influenza • Malnutrition-related phenomena: ↓secretory IgA, failure of
o Increases adhesion of S. pneumonia and H. m∅ recruitment, alterations in cellular immunity à
influenzae to the oropharyngeal epithelium ↑colonization by gram-negative bacilli
• Alters mucociliary transport and humoral and cellular • immunodeficiency states: e.g., neutropenia,
defenses, affects epithelial cells lymphoproliferative dses, immunoglobulin deficiencies,
HIV]infection
CAP Co-morbidities
COPD   CAP Geographic and Occupational Considerations
• Most frequent comorbidity associated with CAP • S. pneumoniae occurs in soldiers, painters, South
• Microorgs frequently colonize the lower airways of African gold miners
patients with COPD • Burkholderia pseudomallei (melioidosis) is endemic
• Important alterations in mechanical and cellular defenses in the rural tropics
• Persons with severe COPD (FEV1 < 30% of predicted) • Animal exposure - zoonotic pneumonia
and bronchiectasis à ↑risk for pneumonias c/b H. o Birds- psittacosis
influenzae and P. aeruginosa . o Horses- Rhodococcus
• Pts tx w/oral corticosteroids for long periods à ↑risk o Rodent - Yersinia pestis (plague)
of infection by Aspergillus spp o Francisella tularensis (tularemia)
  o Sheep, dogs, cats - C. burnetii (Q fever) in Nova
Scotia, Australia, Basque region of Spain
• Winter month - infections due to S. pneumoniae and H.
Influenzae

Common Causes of Community-Acquired Pneumonia in Patients Who

DO NOT Require Require Hospitalization Require ICU
Hospitalization (in general order of frequency)
All usually MILD
1. Mycoplasma 1. Streptococcus Common causes of Severe 1. Streptococcus pneumoniae
pneumoniae pneumoniae Enteric gram-negative bacilli
2. Streptococcus 2. Haemophilus influenzae 2. Staphylococcus aureus
pneumoniae 3. Mycoplasma pneumoniae 3. Legionella spp.
3. Chlamydophila 4. Aspiration (anaerobes) 4. Mycoplasma pneumoniae
pneumoniae 5. Chlamydophila pneumoniae 5. Respiratory viruses
4. Haemophilus 6. Enteric gram-negative bacilli Uncommon causes of Severe, 6. Pseudomonas aeruginosa
influenzae 7. Respiratory viruses account for <5%
5. Respiratory 8. Legionella spp. MRSA, originally a nosocomial
viruses 9. S. aureus pathogen, appeared in recent times
in community and are referred to
community-acquired MRSA. CA-
MRSA can lead to severe
pulmonary infections, incl
necrotizing & hemorrhagic
pneumonia
10. Mixed infections 10-20% 7. Polymicrobial
Up to 20% of severe CAP infection; h/e,
even if extensive dx procedures are
performed, responsible pathogen is not
isolated in up to 50-60%.
11. Pseudomonas aeruginosa Relatively uncommon, (determined
by ± of specific risk factors:
previous antibiotic tx, structural
lung dse like bronchiectasis, CF)

Lecture 3 mra
Med3C Abarra - Pneumonia Pulmo

Hospital-Acquired (Nosocomial) Pneumonia Ventilator Associated Pneumonia (VAP)

(HAP) • Subset of HAP
• Pneumonia 48 hours or more after admission to hospital • Defined as pneumonia in a mechanically ventilated patient
• Severe HAP - defined by concomitant occurrence of that occurs >48 hours after intubation.
o Sepsis syndrome • Antibiotic regimens recommended for empirical tx of HAP
o Respiratory failure typically incl:
o Rapid progression of CXR shadows o Expanded-spectrum β-lactam agents,
o Multilobar involvement or often given in combination with
o Cavity formation aminoglycosides or vancomycin.
Early-onset HAP (<5 days Late-onset HAP (>5 days • If aspiration is likely, specific treatment for anaerobes
(metronidazole, clindamycin) must be strongly
of hospitalization) of hospitalization)
considered.
• S. pneumoniae, H. • MRSA, enteric gram-
• Unless Legionella known to be endemic in institution,
influenzae, and negative bacilli, P.
targeted therapy for this pathogen is seldom necessary
anaerobes aeruginosa
• Empirical VAP tx is necessarily broad - range of potential
• Non-fermenters:
pathogens is large and mortality is significantly increased
Acinetobacter baumanii
when responsible pathogen is resistant to initial antibiotic
and S. maltophilia,
regimen

Factors that increase the risk of HAP High Risk Criteria

• Exposure to antibiotic or contaminated respi equipment • Age ≥ 65 years
• Old age • Pancreatitis
• Severe comorbidities, immunosuppression • Chronic obstructive pulmonary disease (COPD)
• Colonization of oropharynx by virulent microorganisms • CNS dysfunction (stroke, drug overdose, coma, status
• Conditions that promote pulmonary aspiration or inhibit epilepticus)
coughing (thoracoabdominal surgery, endotracheal • Congestive heart failure
intubation, insertion of nasogastric tube, supine position) • Malnutrition
• Diabetes mellitus
Health Care–Associated Pneumonia • Endotracheal intubation
• S. aureus (both methicillin-sensitive and -resistant) and • Renal failure
P. aeruginosa were the most frequent microorganisms • Complicated thoracoabdominal surgery
• More severe dse, higher mortality, greater length • Alcoholism
of stay • All other patients are considered to be at low risk.

Nursing Home-Acquired Pneumonia

• Etiology of bacterial pneumonia in nursing home residents
is diverse
o HAP-assoc - aerobic G(-) rods, S. aureus
o CAP-assoc - S. pneumoniae, H. influenzae,
“atypicals”, and anaerobes (d/t aspiration risk)
• Particular attention s/b paid to providing adequate tx for
o S. pneumoniae in all patients and
o Gram-negative bacilli, esp in pts w/severe CAP in
setting of significant medical comorbidities or
recent antimicrobial tx

Typical vs Atypical Pneumonia Syndrome

Atypical pneumonia Typical Pneumonia
Etiology • M. pneumoniae • S. pneumoniae
• Chlamydophila spp. • H. influenzae
• C. burnetii , • Klebsiella spp (e.g. pneumoniae)
• Viruses • Mixed aerobic & anaerobic oral flora
Onset • Gradual • Abrupt/acute
Cough • Non-productive, dry • Productive
Sputum • Scanty • Purulent or bloody
Pulmo s/sx • Shortness of breath • Shortness of breath
• ~Pleuritic pain - very specific to S. Pneumoniae
• Typical findings of pulmonary consolidation
• Rales
Extrapulmo s/sx • Freq, systemic complaints more prominent than respiratory • Intense and unique chill
• Not prominent
Lab • Relatively normal white blood cell • Leukocytosis w/neutrophilia and band forms
CXR • Lobar condensation with air bronchograms

Lecture 4 mra
Med3C Abarra - Pneumonia Pulmo

PATIENT EVALUATION
Chest X ray (PA-Lateral views)
Clinical Evaluation • New parenchymal infiltrate
• Best differentiate CAP from other acute RTI: • Confirms diagnosis
o Cough, fever, tachypnea, tachycardia, and • Assess severity / prognostication
pulmonary crackles • May suggest the etiology
o CAP is present in 20% to 50% of persons who
have all four factors
• Must look for presence of cx such as
o Pleural effusion, pericarditis, endocarditis,
arthritis, and CNS involvement
o Which may necessitate further dx procedures
and/or change in therapy

Clues to etiologic dx outside RT

Extrapulmo S/Sx Associated with
Bradycardia - in relation to • Legionella
amount of fever • Chlamydophila
psittaci
• Mycoplasma
• Tularemia
~Arthralgia, cervical LAD, bullous • Specifically M.
myringitis, diarrhea, myalgia, pneumoniae
myocarditis, hepatitis, nausea,
pericarditis, and vomiting
Erythema multiforme or erythema • Mycoplasma
nodosum
Ecthyma gangrenosum • Most commonly with
P. aeruginosa
infection • Typical pneumonia - + air bronchograms and a
lobar/segmental pattern
Laboratory Evaluation • Atypical pneumonias- a mixed pattern (alveolar and
• Blood cell counts, serum glucose and electrolyte interstitial dse
measurements, and pulse oximetry or arterial blood gas • Pneumonia complicating aspiration (from anaerobes)
assays o Most often involves
• HIV testing s/b offered in severe CAP in areas where rate § Superior segment of RLL or
of newly detected HIV infection exceeds 1/1000 hospital § Posterior segment of RUL or
discharges. § Both + corresponding segments on left
• Infections from hematogenous seeding - often appear as
Marked leukocytosis S. pneumoniae, H. influenzae, and
multiple rounded shadows sometimes with cavities in
with leftward shift gram-negative bacilli
greatest distribution of blood flow.
Leukopenia Overwhelming pneumococcal or
• Although several radiologic patterns have been assoc
gram-negative bacillary pneumonia.
w/pneumonia c/b specific microorgs, this is not a
reliable method for diagnosing a specific
Procalcitonin pathogen
• Precursor of calcitonin released into blood of persons with o Lung abscess, cavitation, or necrotizing
bacterial infections. pneumonia suggests anaerobes, S. aureus, or
• Useful to evaluate severity and prognosis and to gram-negative bacilli
deescalate antibiotic treatments • Pleural effusion - frequently accompanies pneumonia and
• Routine use in the initial evaluation of CAP needs further has management implications
evaluation. o Size on CXR helps decide whether to perform a
thoracentesis.
Radiographic Evaluation
• Necessary to establish the presence of pneumonia Microbiologic Evaluation
• ↓Sensitivity of CXR • Serves to verify clinical dx of infection
(1) Pts w/emphysema, bullae, or struc abn of lung • Facilitates use of specific therapy instead of
(2) Obese patients unnecessarily broad-spectrum antimicrobial agents.
(3) Pts w/very early infection, severe dehydration, or • Although the utility of sputum examination is much
profound granulocytopenia debated, pleural fluid (if present) and two sets of blood
cultures should be obtained in patients hospitalized for
CAP.

Lecture 5 mra
Med3C Abarra - Pneumonia Pulmo

T32-5 Recommended Microbiologic Evaluation in Patients with CAP

Pts Who Require Hospitalization
• Two sets of blood cultures
• Gram stain and culture of a valid sputum sample
IF
Endemic areas
TB suggested by hx or CXR
Infection by an endemic mycosis
suggested by clinical hx or CXR
Suggested by clinical hx or CXR
Endemic areas or during outbreaks
(+) Significant pleural fluid
Pts Who Require ICU
• Gram stain (GS) and culture of valid
sputum sample, endotracheal
THEN aspirate, or bronchoscopically
Urinary antigen test for detection of Legionella obtained specimens using a
pneumophila protected specimen brush or BAL
Stain for AFB and culture of sputum • Other procedures as for other
hospitalized patients
Fungal stain and culture of sputum, and fungal
serologies
Sputum exam for Pneumocystis jirovecii
Serologies for M. pneumoniae, C. pneumoniae, C
psittaci, Coxiella burnetii, Legionella spp., and
RSVs
Culture and microscopic eval of pleural fluid

T32-16 Recommended Microbiologic Evaluation in Pts with Non-Resolving Pneumonia

Blood cultures (Two Sets)
Urine Antigen test for detection of L. pneumophila
Sputum GS, Giemsa stain, IF stains for Legionella
Normal and modified Ziehl-Neelsen stain for Mycobacterium spp. And Nocardia spp.
Cultures for conventional bacteria, Legionella mycobacteria, and fungi
Bronchoscopy Specimens (using PSB or BAL) GS, Giemsa stain, IF stains for Legionella and P. jirovecii
Normal and modified Ziehl-Neelsen stain for Mycobacterium spp. And Nocardia spp.
Cultures for aerobic and anaerobic bacteria, Legionella mycobacteria, and fungi
Pleural fluid GS, Giemsa stain, IF stains for Legionella and P. jirovecii
Normal and modified Ziehl-Neelsen stain for Mycobacterium spp. And Nocardia spp.
Cultures for aerobic and anaerobic bacteria, Legionella mycobacteria, and fungi

Examination of the Sputum Antigen Detection

• Micro exam of expectorated sputum is easiest and most
rapidly available method of evaluating microbiology of
LRTI
• (+) >10 squamous epithelial cells /LPF à excessive
oropharyngeal contamination
• Specimen with few or no squamous cells and
many PMNs (>25 cells/LPF) is ideal
Clinical Indications for More Extensive Testing in Community-
Acquired Pneumonia
(IDSA/ATS guidelines - sputum sample for stain and
culture)
• ICU admission
• Failure of outpatient antibiotic therapy
• Radiographic cavities
• Leukopenia
• Active alcohol abuse
• Chronic severe liver disease
• Severe obstructive/structural lung disease
• Asplenia
• Recent travel (within past 2wk)
• Positive Legionella Urinary Ag Test result
• Positive pneumococcal Urinary Ag Test result
• Pleural effusion
Blood and Pleural Fluid Cultures
• Although overall yield of blood cultures is probably <20%
in hospitalized CAP pts, a positive culture of blood or
pleural fluid definitively establishes etiologic dx of
pneumonia
Lecture
• ~Commercial assays - rapidly detect urine capsular
polysaccharide Ags
• L. pneumophila serogroup 1 - sensitivity 60-80%,
specificity >95%.
• S. pneumoniae - sensitivity 50- 80%, specificity 90 %
Serologic techniques
• Often most practical means to establish a microbiologic dx
for pneumonia caused by pathogens that cannot be
readily cultured
o M. pneumoniae, C. pneumoniae, L. pneumophila
o Less common causes e.g. those c/b agents of
tularemia, brucellosis, and psittacosis; and viral
• Dx requires convalescent specimen demo a 4-fold rise in
IgG titer above acute specimen
Invasive Diagnostic Techniques
• Problems w/use of expectorated sputum may necessitate
invasive procedure, e.g.:
o Mgmt of life-threatening CAP
o Progressive pneumonia despite seemingly
appropriate antimicrobial tx
o Immunocompromised
o HAP, esp w/endotracheal intubation
Bronchoscopic Samples
Transthoracic Lung Aspiration
• Obtains specimens suitable for microbiologic and
cytologic exam directly from lung parenchyma
• Diagnostic yield is ~50%
• Sensitivity of 35-82%
• Serious complications: pneumothorax (2%–5%) and
hemoptysis (2%–5%)
6 mra
Med3C Abarra - Pneumonia Pulmo

THERAPEUTIC APPROACH TO PNEUMONIA

1. Once dx of pneumonia has been made, clinician must
decide whether the patient can be managed in the
outpatient setting.
2. Second key decision is selection of initial
antimicrobial therapy.
3. Assessment of Severity

The PSI (Pneumonia Severity Index) PSI Score Mgmt and Prognosis
• Point scoring system 70  or  less  (class  I  or  II)     71  to  90  (class  III)  
• Retrospective analysis of a cohort of 14,199 CAP pts • Attributable  risk  of  death   • 30-­‐day  mortality  rate  of  up  to  
(1989) within  30  days  of  <  1%     2.8%    
• Prospectively validated in a separate cohort of 38,039 • Outpatient  treatment  is   • May  benefit  from  brief  
recommended.     hospitalization.  
CAP pts (1991)
• Age - most significant risk factor
o 1 point given for each year of age (−10 points in
women). 91  to  130  (class  IV)   More  than  130  (class  V)  
• Other risk factors: pt demographics, comorbid conditions, • 30-­‐day  risk  of  death  of  8.2-­‐9.3%,     • 30-­‐day  risk  of  death  of  27.0-­‐  
PE findings, and lab results • Hospital  care  is  appropriate     31.1%.  
• Hospitalization  is  appropriate  
• Safely and effectively applied in clinical practice
• Less useful at extremes of age, ∴aged-based criteria have
been developed for children and elderly.
• < 50 = candidates for outpatient tx
• 70–90 = careful application of clinical judgment. CURB 65
• > 90 = warrant hospitalization • Grading the severity of CAP by the British Thoracic
Society
T32-9 Scoring System for Determining Risk of Complications • 1 point for each of the following findings upon
in Pts w/CAP presentation
(1) Confusion
Factors/Findings Pt Characteristic Points
Assigned (2) Urea higher than 7mmol/L
(3) Respiratory rate of 30/min or more
Demographic Males Age (in yr)
(4) Low systolic (<90mmHg) or low diastolic
Females Age (in yr) – (≤60mmHg) BP
10 (5) Age 65 years or older.
Nursing home Age (in yr) + Group Curb 65 30-day mortality rates (MR) for
residents 10 Score patients
Comorbid Neoplastic dse +30
1 0 or 1 1.5% outpatient
Illnesses Liver dse +20 2 2 9.2% brief inpatient /supervised
Congestive heart +10 outpatient
failure 3 3–5 22% inpatient
Cerebrovascular dse +10 ICU care for scores of 4 or 5
Renal dse +10
PE Altered mental status +20 American Thoracic Society Criteria for
RR ≥30cpm +20
Admission of Pts w/CAP to an ICU
Systolic BP <90mmHg +20 ICU admission warranted for 3 minor criteria or 1
Temp <35°C or ≥40°C +15 major criterion
Pulse ≥125bpm +10 Minor Criteria Major Criteria
Lab pH <7.35 +30
• RR ≥30 cpm • Invasive mechanical
BUN >10.7 mmol/L +20 • PaO2/FiO2 ratio <250 ventilation
Sodium <130 mEq/L +20 • Multilobar radio involvement • Septic shock with
Glucose >13.9 mmol/L +10 • Confusion or disorientation need for
Hematocrit <30% +10 • Uremia (BUN > 20 mg/dL) vasopressors
pO2 <60mmHg or +10 • Leukopenia (WBC ct <4000
O2Sat <90% cells/dL)
Pleural effusion +10 • Thrombocytopenia (platelet ct
<100,000 cell/dL)
• Hypothermia (core temp
<36°C)
• Hypotension req aggressive
fluid resuscitation

Lecture 7 mra
Med3C Abarra - Pneumonia Pulmo

Phil Clinical Practice Guidelines

Clinical features of patients with CAP according to risk categories
Low Risk CAP Moderate Risk CAP High Risk CAP

• Stable vital signs • Unstable vital signs Any of clinical ft of moderate risk CAP plus
o RR<30 cpm o RR ≥ 30 cpm any on ff:
o PR <125 bpm o PR ≥ 125 bpm • 1. Shock or signs of hypoperfusion
o SBP ≥ 90mmHg o Temp ≥ 40C or >35C o Hypotension
o DBP ≥ 60 mmHg • Unstable comorbid condition, i.e. o Altered mental state
• No or stable comorbid conditions o uncontrolled DM o Urine output < 30ml/hr
• No evidence of extrapulmonary o active malignancies • 2. Hypoxia (PaO2<60mmHg) or Acute
sepsis o progressing neuro dse Hypercapnea (PaO2>50mmHg)
o CHF Class II-IV, unstable CAD
o renal failure on dialysis
o uncompensated COPD
o decompensated liver dse

• No evidence of aspiration • Evidence of extrapulmonary sepsis • Chest X-ray:

• Chest X-ray:
o Localized infiltrates
o No evidence of pleural
effusion nor abscess
o Not progressive w/in 24
hrs
Ihepatic, hema, GI, endocrine) o Same as moderate risk CAP
• Suspected aspiration
• Chest X-ray:
o Multilobar infiltrates
o Pleural effusion or abscess
o Progression of findings to >50%
in 24 hrs

Algorithm for the management–oriented risk stratification of

CAP in immunocompetent Adults
Selection of Antimicrobial Agents
• Initial treatment for pneumonia should be pathogen-
directed
• Unfortunately, pathogens are rarely identified at time of
presentation, esp when patients are seen in outpatient
setting
• When selecting initial empirical antimicrobial therapy,
physicians should consider
o setting in which pneumonia occurs (community,
hospital, nursing home)
o severity of the disease
o age of the patient
o presence of comorbidities and
immunosuppression
o previous antimicrobial therapy,
o specific clinical manifestations of illness.
• In hospitalized pts,
o specimens for cultures of blood, sputum, and
pleural fluid (if present)
o s/b obtained prior to treatment.
• Delays of >8 hours – assoc w/↑ mortality and ~otherwise
increase length of hospitalization

Lecture 8 mra
Med3C Abarra - Pneumonia Pulmo

Guidelines for Empirical Oral Outpatient Treatment of Immunocompetent Adults with Community-Acquired Pneumonia
British  Thoracic  Society   Drug  Resistant  S.  pneumoniae   American  Thoracic  Society   Infectious  Dses  Society  of   Canadian  Infectious  Dse  Society  &  
Therapeutic  Working  Group     America   Canadian  Thoracic  Society  
Primary No modifying factor
Amoxicillin Macrolide, doxycycline, Advanced macrolide or Advanced macrolide or Macrolide or doxycycline
cefuroxime, amoxicillin, doxycycline doxycycline
amoxi-clav
Alternatives Comorbidities/modifying factors: COPD
Erythromycin or Fluoroquinolone β-lactam macrolide or Fluoroquinolone or Advanced macrolide or
clarithromycin doxycycline, or fluoroquinolone advanced macrolide doxycycline
alone IDSA Co-morbidities:
ATS Co-morbidities: • COPD
• Cardiopulmonary dse and • Diabetes
age > 65yo • Renal failure
• β-lactam antbx w/in last • Congestive heart
3mo failure
• Alcoholism • Malignancy
• Prior immunosuppressive tx Antibiotics within 3mo: COPD plus recent antibiotics or
• Multiple medical steroids:
comorbidities Fluoroquinolone alone or Fluoroquinolone alone, amoxi-clav,
nd
• Exposure to a child in a advanced macrolide β- macrolide, 2 –gen
daycare center lactam cephalosporin, macrolide
• Residence in a nursing Nursing home patient:
home Fluoroquinolone alone or Fluoroquinolone alone or
nd
amoxi-clav, advanced macrolide plus amoxi-clav or 2 -
macrolide gen cephalosporin
Suspected aspiration:
Clindamycin or amoxi-clav Amoxi-clav, macrolide, or
fluoroquinolone, clindamycin or
metronidazole
Influenza with bacterial
superinfection:
β-lactam or
fluoroquinolone

Guidelines for Empirical Oral Outpatient Treatment of Immunocompetent Adults with CAP: MILD TO MODERATE or SEVERE DSE
British  Thoracic  Society   Drug  Resistant  S.  pneumoniae   American  Thoracic  Society   Infectious  Dses  Society  of   Canadian  Infectious  Dse  
Therapeutic  Working  Group     America   Society  and  Canadian  
Thoracic  Society  
Primary No modifying factors: Primary:
(Ampicillin or penicillin) a (Cefuroxime, cefotaxime, Azithromycin alone, doxycycline, (Cefotaxime, ceftriaxone, Fluoroquinolone or
macrolide ceftriaxone, or ampicillin- β-lactam or fluoroquinolone alone ertapenem, or (cephalosporin
sulbactam) macrolide ampicillin/sulbactam) macrolide)
advanced macrolide or
fluoroquinolone alone
(Cefuroxime, cefotaxime, or (Cefotaxime or ceftriaxone) (Cefotaxime, ceftriaxone,
ceftriaxone) macrolide, (azithromycin or fluoroquinolone) ertapenem, or
rifampin ampicillin/sulbactam)
(advanced macrolide or
fluoroquinolone)
Alternative: With modifying factors: Suspected aspiration:
Fluoroquinolone Fluoroquinolone (Cefotaxime or ceftriaxone or Fluoroquinolone,
ampicillin-sulbactam or high-dose antianaerobic agent
ampicillin) (macrolide or
doxycycline) or fluoroquinolone
alone
Fluoroquinolone, penicillin IV At risk for Pseudomonas β-Lactam allergy:
aeruginosa: antipseudomonal β- fluoroquinolone,
,
lactam ciprofloxacin or clindamycin
antipseudomonal, β-lactam Pseudomonas risks:
,
aminoglycoside plus (azithromycin (antipseudomonal β-lactam
or fluoroquinolone) ciprofloxacin) or
antipseudomonal β-lactam
aminoglycoside
(fluoroquinolone or a
macrolide)
Pseudomonas risks and β-
lactam allergy: (aztreonam
levofloxacin) or aztreonam
(moxifloxacin or
gatifloxacin) an
aminoglycoside

Lecture 9 mra
Med3C
Empiric Treatment- Philippine Consensus Guidelines
Low
 Risk
 CAP
  Moderate
 Risk
 CAP
  High
 Risk
 CAP
• Previously healthy: amoxicillin or • IV non pseudomonal B lactams (w/ or
extended macrolide, alternative: w/o B lactamase inhibitor,
cotrimoxazole cephalosporin, carbapenem) PLUS
• With stable co morbid illness: co- macrolide OR IV non pseudomonal B
nd
amoxyclav OR sultamicillin OR 2 lactam PLUS antipneumococcal
gen cephalosporin PLUS extended fluoroquinolone
rd
macrolide; Alternative: 3 gen
cephalosporin +/- extended macrolide
Adjustments in Antimicrobial Therapy
• Orgs recovered from normally sterile sites (blood, pleural
fluid, CSF, or transthoracic lung aspiration specimens) are
presumed to be pathogens
• Expectorated sputum culture results must be interpreted
in light of
o Quality of specimen
o Correlation w/pathogens identified by Gram stain
o Clinical impression.
• Pathogen-based modification of therapy is particularly
important in HAP
Commo n Cause s of Pyogenic Pneumo nia
STREPTOCOCCUS PNEUMONIAE (PNEUMOCOCCAL PNEUMONIA)
Epidemiology
• S. pneumoniae is the most frequent cause of CAP
among patients who require hospitalization.
• Risk factors for infection:
o Male sex
o Chronic liver or kidney dse, CHF
o Age younger than 2 years or older than 65 years
o African American or Native American ancestry
o Heavy alcohol use, cigarette smoking,
malnutrition
o Dementia, institutionalization
o COPD, immunoglobulin deficiency, HIV infection,
and organ transplantation.
• Transmitted by aerosolized droplets and direct
physical contact
Clinical Manifestations
• Classic presentation of pneumococcal pneumonia
o Single rigor (shivering or trembling, unresponsive
to stimuli)
§ followed within a few hours by
o Sustained fever and the devt of cough, dyspnea,
and production of rusty or mucoid sputum
• Severe pleuritic chest pain is common
• Chest exam (early stages of infection)
o localized crackles
o focal decreased breath sounds
• Eventually, signs of consolidation evolve
• ~Neutropenia in overwhelming infection
Lecture
Abarra - Pneumonia Pulmo
• No risk for P. aeruginosa: IV non-
pseudomonal B lactam w/ or w/o B
lactamase inhibitor plus IV macrolide
or IV antipneumococcal
fluoroquinolone
• W/ risk of P. aeruginosa: IV
antipseudomonal B lactam w/ or w/o B
lactamase inhibitor plus IV macrolide
plus aminoglycoside OR IV
antipseudomonal B lactam w or w/o
BLIC plus IV Ciprofloxacin or
Levofloxacin (high dose)
o Prolonged use of broad-spectrum empirical
agents à multidrug resistance emergence
• If pathogen is not identified, reevaluation of initial
therapeutic regimen must take into account patient's
response to therapy
• Change from parenteral to oral antimicrobial therapy can
safely be made in CAP patients who are
o clinically stable
o able to absorb effective oral antimicrobials
o often achieved w/in 3 days of parenteral initiation
Radiographic Diagnosis
• Either lobar consolidation or patchy
bronchopneumonia
• Bacteremia: lobar opacities > multilobar or bilateral
disease.
• Cavitation is rare
• Small, sterile parapneumonic effusions - frequently found.
Microbiologic Diagnosis
• GS of purulent sputum:
o “Lancet-shaped” diplococci with blunted
ends (commonly seen in pairs and short chains)
o In the absence of other predominant flora
o Strongly suggestive of the dx
• Blood cultures are positive in 10-30% of hospitalized
patients.
• Urinary antigen S. pneumoniae test
o Rapid
o Sensitivity 50-80% (higher in bacteremic cases)
o Specificity ~90%
Clinical Course
• With an appropriate antibiotic clinical response within
24 to 48 hour
• Fever may persist for up to 5 days w/o signifying
therapeutic failure or complication of the infection.
• Resolution of radiographic changes occurs in 4 to 8 weeks
(up to 12 weeks)
• The overall mortality of 11% to 20%
o Increasing to 20% to 40% in persons over 65
years of age.
10 mra
Med3C Abarra - Pneumonia Pulmo

OTHER STREPTOCOCCI
S. pyogenes (group A β-hemolytic Group B streptococci (S. Streptococcus milleri
streptococcus) agalactiae) group C streptococci
• In oropharynx of over 20% of children • Major cause of neonatal sepsis • S. intermedius, S. anginosis,
o Smaller %age of adults and pneumonia and S. Constellatus
• Easily transferred btwn contacts • Most adults are debilitated and • Predominantly causing
o à Epidemics of group A strep pneumonia in develop pneumonia d/t aspiration. empyema and lung
military recruits, nursing homes, and other abscesses
crowding situations
• Most often - late winter and spring months
o ~post- influenza, measles, or varicella
• Risk factors: ↑age, alcohol abuse, DM, cancer, and HIV • Diabetes, hepatic cirrhosis, stroke, • Males, periodontal dse, and
infection. breast cancer, decubitus ulcer, alcoholism
neurogenic bladder
• Unilobar involvement is common • •
• Empyema and/or pericarditis occur in 5% to 30% with • •
GABS pneumonia
• Glomerulonephritis- only classic non-suppurative
complication post-S. pyogenes pneumonia

Clinical Manifestations Microbiologic Diagnosis

• Exudative pharyngitis may be evident • Orgs are indistinguishable from streptococci in normal
oral flora à documentation requires isolation from a
Complications culture of sterile site (blood, pleural fluid, or respiratory
• The overall mortality rate (MR) is 24-38% specimen obtained by means of an invasive procedure)

CHLAMYDOPHILA HAEMOPHILUS INFLUENZAE MYCOPLASMA PNEUMONIAE

PNEUMONIAE
rd
Epidem- • fmk Chlamydia pneumoniae • 3 most common cause of • Up to 37% of CAP in outpatient
iology • 5-15% of cases of CAP CAP req hospitalization in • 10% of persons req hospitalization.
nd
• Generally, 2 most common adults • Readily transmitted person to person
cause of CAP requiring • Most common risk factors: via aerosolized respiratory
hospitalization. Chronic lung dse, malignancy, HIV, droplets, ∴outbreaks are common
• Airborne transmission of alcoholism and esp **active in families or closed populations.
infected respiratory droplets smoking
CM • Primary infection usu asx • Indistinguishable from other • Paradigm of atypical CAP
• ~Bronchitis, sinusitis, laryngitis, bacterial pneumonias • Chest auscultation ~normal
tonsillitis, or exacerbations of • Bacteremia more common in • Sometimes crackles and decreased
asthma w/o/w/o assoc children breath sounds
pneumonia. • ~Pharyngitis and cervical adenopathy
• Diarrhea is common in • Wide variety of exanthems:
hospitalized maculopapular eruptions, urticaria,
erythema multiforme, and erythema
nodosum- in 10% to 25% of pts
CXR • Nonspecific alveolar opacities. • Multilobar, patchy • Usu interstitial or a mixed pattern that
bronchopneumonia or have areas is often more striking than expected
of frank consolidation. based on PE
• ~Spherical radio shadows • Nonspecific
(“round pneumonia”) but
cavitation is uncommon.
Microbio Criteria for serologic dx of acute • Dx by a Gram stain of sputum is •
Dx infection: difficult
• MicroIF IgM titer of ≥1:16 or • Small, pleomorphic
• IgG titer of ≥1:512 or coccobacilli - often overlooked
• 4-fold rise in Ab titer ff acute or are misidentified
infection
Clinical Course • Complete recovery is the rule • Overall MR - 5-7% • Usu benign, often self-limited
• Much higher if bacteremia or • Excellent prognosis for complete
extrapulmonary dse recovery.
Other • • • Fulminant intravascular hemolysis, SJS,
complications aseptic meningitis,
meningoencephalitis, pericarditis, and
myocarditis

Lecture 11 mra
Med3C Abarra - Pneumonia
STAPHYLOCOCCUS AUREUS  PSEUDOMONAS AERUGINOSA & RELATED ORGS 
Epidemiology
• Accounts for less than 10% of cases of CAP
•
nd rd
2 -3 most common in CAP requiring ICU admission.
• S. aureus, esp MRSA à up to 30% of nosocomial
pneumonias.
• Nasal or skin colonization - major source
o 30-50% of healthy adults carry transiently in
anterior nares
o MRSA pneumonia - nasal colonization on
admission in 67%
§ Noncolonized have <5% risk of
subsequent MRSA pneumonia
o HCWs may have even higher carriage rates
• Easily person to person by direct hand contact
MRSA-CAP
• Community-acquired strain of MRSA has recently become
an important CAP pathogen in the US
o D/t antibiotic resistance + Virulence factors
§ Combo is assoc w/sig higher mortality.
o DNA cassette containing mecA gene also
included other virulence factors, such as the
Panton-Valentine leukocidin (PVL).
• Typical HAP strains of MRSA have also caused episodes
of CAP but usu occur in pts with risk factors for HCAP
• Difficult to differentiate clinically btwn HAP and CAP
o Risk factors, e.g. antibiotic therapy overlap.
Risk Factors
• Underlying pulmonary disease (e.g., COPD, carcinoma, CF)
• Chronic illness (e.g., diabetes mellitus, renal failure)
• Viral infection (e.g., influenza, measles).
Postinfluenza bacterial pneumonia
• S. aureus (incl MRSA-CAP), is 2 n d to S. pneumoniae as a
cause
• MRSA-CAP is particularly virulent.
• By hematogenous spread usu as consequence of
o IV drug abuse
o Septic embolization (endocarditis setting)
o Infected vascular site
Clinical Manifestations
• Acquired hematogenously, s/sx related to underlying
endovascular infection predominate
o If pulmonary infarction d/t septic embolism à
pleuritic chest pain and hemoptysis
• RT sx - mild or absent
o H/e, radiographic evidence of multiple
pulmonary opacities
• Severe manifestations - more common if infected by S.
aureus w/PVL toxin
o High-grade fever, massive hemoptysis,
neutropenia, pulmonary necrosis, and mortality
o Often cavitary dse already at presentation à
confusion with lung abscess or hematogenous S.
aureus
o Rapid progression of pulmonary opacities and
massive pleural effusions is also common.
• CXR in hematogenous - multiple, discrete, and often
cavitary shadows with a predilection for the lower lobes
Lecture
Pulmo

Epidemiology
CAP
• P. aeruginosa is an uncommon cause of CAP.
• Major risk factor is structural lung disease
o Cystic fibrosis, bronchiectasis, and severe COPD
(FEV1 < 30%).
• Another common risk factor in outpatient is frequent
antibiotic use.
• Very rarely, in a normal hosts, perhaps related to aerosols
of contaminated water
HAP and VAP
• A leading cause of nosocomial pneumonia and a
particularly frequent cause of VAP
• Primary risk factors in VAP
o Prolonged ET intubation
o Prior antibiotic therapy, esp w/broad-spectrum
antibiotics
o Other: administration of aerosols from
contaminated respiratory therapy equipment.
• Other nonfermenters, such as S. maltophilia and B.
cepacia, carry the same nosocomial risk factors
o most commonly prolonged broad-spectrum
antibiotic therapy
o are associated with a high MR
o B. cepacia is also found in CF, outpt
Clinical Manifestations
• Largely indistinguishable from that of pneumonia
due to one of the Enterobacteriaceae
• Bacteremic pneumonia appears much more toxic.
• PE: ecthyma gangrenosum and leukopenia
• CXR: often bilateral patchy bronchopneumonia in lower
lobes
• Labs & PE: ~resemble pulmonary thromboembolism.
o Because of its propensity to invade vascular
tissue
• Pseudomonas HAP is the most common cause of
cavitary pneumonia in hospitalized or
immunocompromised
o Empyema is not uncommon
Microbiologic Diagnosis
• GS of sputum: purulence and many slender, gram-
negative bacilli
o Complicated by colonization of oropharynx in
hospitalized or debilitated
• In ET intubated, absence of Pseudomonas on culture is
strong evidence that it is NOT involved in the pneumonia.
• Invasive diagnostic procedure
o Esp useful in immunocompromised or
neutropenic patients
o B/c sputum may be minimal or nondiagnostic
• Blood cultures are often positive in neutropenic patients.
Clinical Course
• MR of P. aeruginosa CAP is up to 28%
• MR of P. aeruginosa VAP is 40-70%
• Prognosis in neutropenic pts is particularly poor
12 mra
Med3C Abarra - Pneumonia
ACINETOBACTER BAUMANII  IMAGING STUDIES
Epidemiology
• Member of family Achromobacteriaceae
• Gram-negative bacillary cause of pneumonia
• CAP or HAP
CAP
• [US] Most commonly seen in men who abuse alcohol
• Also assoc w/hot climates - both dry and humid
• Additional risk factors include old age, alcoholism, and
severe medical comorbidities
HAP
• Not uncommon
• D/t aspiration of endogenous flora or by exposure to
contaminated respiratory equipment.
• [US] Overall risk is 7.6/10,000 ventilator-days
Seasonal variation, peaking in late summer
•
Clinical Manifestations
• CAP: acute onset of severe respiratory distress,
tachypnea, fever, productive cough, and pleuritic pain.
• Leukopenia, pleural effusions, and empyema are common.
• HAP: less dramatic, similar to those of other hospital-
acquired gram-negative bacillary pneumonias.
Microbiologic Diagnosis
• Expectorated sputum – usu purulent
• May reveal predominance of paired gram-negative
coccobacilli that resemble Neisseria, Haemophilus, and
Moraxella spp.
Clinical Course
• Bacteremia complication in CAP > HAP
• MR of CAP is close to 50%
o Greatest risk of death - leukopenia or
empyema
• Fatality rate for nosocomial Acinetobacter pneumonia
determined by severity of underlying dse
LUNG ABSCESS
• Pus-containing necrotic lesions of the lung
parenchyma that often contain an air-fluid level.
• Similar process with multiple small cavities <2cm in
diameter has been designated necrotizing pneumonia
by some clinicians.
• Associated with infections c/b
o Pyogenic bacteria
o Mycobacteria
o Fungi and
o Parasites
• May also complicate
o Pulmonary infarction
o Primary and metastatic malignancies
o Necrotic conglomerate lesions of silicosis and
coal miners’ pneumoconiosis
Lecture
Pulmo
Chest Radiograph
Nonresolving Pleural effusion, cavitation, or new
pneumonia changes.
Progressive Clinical deterioration & extension of
pneumonia radio img ~appear during first 72h
after initiation of satisfactory tx.
P. jirovecii Characteristic ground-glass opacities
pneumonia consistent with interstitial pneumonia
Nocardia spp., M. May have nodules or multiple masses
tuberculosis, or Q w/o/w/o cavitation.
fever
Viral infections or M. May have diffuse or mixed interstitial
pneumoniae. and alveolar opacities
Pulmonary CT Scan
• Provide a more detailed study of the parenchyma,
interstitium, pleura, and mediastinum
• In the right clinical setting, appearance of nodular
images with the halo sign
o (i.e., a nodule surrounded by a halo of ground-
glass attenuation, esp near pleura)
o Suggestive of pulmonary aspergillosis or
mucormycosis.
• Nodules of similar appearance also described in CMV
infection, Wegener's granulomatosis, Kaposi's sarcoma,
and hemorrhagic metastasis.
Other
• E.g. perfusion-ventilation scintigraphy ~perform according
to clinical suspicion of pulmonary embolism
• Spiral CT scans and pulmonary arteriography complement
this diagnostic procedure.
PREVENTION
Vaccinations
• Possible prevention of pneumonia by admin of
pneumococcal and influenza (during flu season) vaccines
for eligible patients
• Recommendations for live, attenuated influenza vaccine
are
o Healthy persons from 5-49 years incl health care
providers
o Household contacts of high-risk patients.
Recommendations for Administration of Influenza Vaccine
• Age ≥ 50yr
• Nursing home resident
• Chronic cardiopulmonary disease (including asthma)
• Chronic metabolic diseases (including diabetes mellitus),
renal dysfunction, hemoglobinopathies
• Immunosuppression (including immunosuppressive
therapy and HIV)
• Children and adolescents (aged 6 months to 18 years)
receiving long-term aspirin therapy
nd rd
• Women who will be in 2 or 3 trimester of pregnancy
during influenza season
• Health care workers (primarily to avoid transmission of
influenza virus to high-risk patients)
• Close contacts of high-risk persons (primarily to avoid
transmission of influenza virus to high-risk patients)
13 mra
Med3C Abarra - Pneumonia Pulmo

KEY POINTS
All  patients  with  suspected  pneumonia  should  have  a  chest  radiograph.  

Gram  stains  and  cultures  of  blood,  sputum,  and  other  sites  should  be  obtained  in  hospitalized  patients  prior  to  treatment.  

Infection  by  aerosolization  route  occurs  with  the  intracellular  bacteria  -­‐  M.  pneumoniae,  Chlamydophila  spp.,  and  C.  Burnetii  

Infection  occurs  by  aspiration  with  S.  pneumoniae,  H.  influenzae,  gram-­‐negative  bacilli  

Aside  from  inhalational  pneumonia  due  to  Legionella  or  contaminated  medical  aerosols,  aspiration  is  the  cause  of  HAP,  especially  in  intubated  
patients  

In  elderly  and  immunocompromised  ps,  s/sx  of  pneumonia  may  be  muted  and  overshadowed  by  nonspecific  complaints.  Elderly  patients  
with  pneumonia  who  present  with  altered  mental  status  without  fever  have  a  delay  in  receiving  antibiotics  and  this  delay  affects  mortality  

Treatment  for  pneumonia  should  be  pathogen-­‐directed,  but  pathogens  are  rarely  identified  initially.  Therefore,  the  setting  in  which  the  
patient  resides  (e.g.,  community,  hospital,  nursing  home),  the  severity  of  the  disease,  the  age  of  the  patient,  the  presence  of  comorbidities  
and  immunosuppression,  previous  antimicrobial  therapy,  and  specific  clinical  and  radiologic  manifestations  of  the  illness  must  be  considered  
If  etiologic  agent  has  been  reliably  identified,  the  antimicrobial  regimen  should  be  adjusted  based  on  the  results  of  in  vitro  susceptibility  
testing.  The  ideal  drug  for  a  known  pathogen  has  the  narrowest  spectrum  of  activity  and  is  the  most  efficacious,  least  toxic,  and  least  costly  

Lecture 14 mra